Provider Demographics
NPI:1316911266
Name:BAACK, MICHELLE L (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:BAACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W. 22ND ST
Mailing Address - Street 2:SANFORD CHILDREN'S SPECIALTY CLINIC
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1521
Mailing Address - Country:US
Mailing Address - Phone:605-312-1000
Mailing Address - Fax:605-312-1001
Practice Address - Street 1:1600 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1521
Practice Address - Country:US
Practice Address - Phone:605-312-1000
Practice Address - Fax:605-312-1001
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4522208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6701280Medicare ID - Type Unspecified
SD6149Medicare ID - Type Unspecified
SDG88462Medicare UPIN